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ICU Nurse Duties and Responsibilities Around the World

Hi everybody, and welcome to the Lefora talk show. This is Season 3 Episode 7. I cannot believe that a Lefora talk show has been going for three years. We are excited to join you today. I am your host, Tanya Freedman, Chief Executive Officer of Connetics USA Nursing Recruitment Agency. We are the number one company for direct hire to the United States. Today we have a very interesting topic and I'm joined by my panel. We have with us Shannon. Hi, Shannon.

Hi, Tanya. Hi, everyone.

Welcome. We are also joined by Holly from Connetics. Hi, Holly. Welcome.

Good morning, or good evening. Hello. In the world.

And last but not least, we are also joined by Mark from me and welcome Mark.

Hello, everyone.

Thank you. Welcome. So our topic today is I see you. And we had on the Lefora talk show, I think it was one or two shows ago, we did a show on the clinical differences about working overseas, whether you're in the Philippines or in the Gulf states or UK, Australia, New Zealand, wherever you are, and the differences overseas as opposed to working in the United States. We then did a poll in the fora. And in the poll, we asked which skill set? are you most interested to find out more about what are the differences and ICU came up with the number top number of votes. So today is all about ICU, we're going to be talking about what the differences are in working as an ICU nurse in the Philippines as well as well as other places in the world as opposed to working in the United States.

We're going to be talking about orientation. What is important in terms of orientation when you come and live in the United States. We're going to be talking about the day to day how is the day to day on the job different overseas as opposed to the US. We're going to be talking about technology. We're going to be talking about culture, cultural differences in the workplace. Lots of advice, lots of pointers and tips. So please sit in please put your names into the chat. Where you're watching from we like to see all over the world we have Mark from Mike sorry, from the Philippines have mined from the Paul James from Saudi Savannah seems an interesting topic. Thank you Shabana. And we have James who's actually texting a number of his friends. So the Lefora talk show everybody is about nurses, helping nurses and paying it forward. So if you are not an ICU nurse, please tag your friends, and make sure that they are watching today. And if you are not an ICU nurse at all, please enjoy the show because you're going to learn a lot about living and working in the United States. Okay, so we're gonna get started. And and Oh, and before we get started, just a shout out to the Lefora talk show  four admin team, to to Paul to Anna, to Louise to Miss Jean, all of them are for admin who do such a fabulous job in this one. And James, in the for admin nurses helping nurses. Okay, so we're gonna get started with introductions. Shannon, let's start with you. Do you want to tell us a little bit about yourself?

Yeah, hi, I'm Shannon, and I've been a nurse for about 2010 years now. So I graduated on 2012 in Xavier University Ateneo de Cagayan. And it's in Cagayan de Oro, Misamis Oriental. Hi, everyone. Everybody's watching. And I took the nursing boards on December 2012. I got my license on around February 2013. Because that's when they published the board passers at that time. And I started the job right away at a local hospital in my province. So I've been there pretty much wrong two to three years. And then I I had the opportunity to go to Manila to have dialysis training because that was initially the track I was going for. And I did everything that training I got my certification in, in as a renal nurse. And then after that, I was I figured out I didn't want to go back to the province because I was already in there and if I wanted to go abroad, I the vicinity to all the agencies and hiring companies are within reach. So I applied a job in there, and I got hired in search Every hospital, it's a joint commission accredited hospital. And I worked there for, let's say, about a year, more than a year. And then I moved to the UK in London on 2016. And I've been working there for about five, six years rather. And just move here the US in May. And he Right, yeah.

Okay, what an interesting story, Shannon. And I know so many of our viewers will relate to your story, because it's, you know, what you experienced is what many people have experienced, the ultimate destination is the US, but sometimes it kind of takes a little bit of a windy route to get to that you still have a little bit of the British accent. So we're really excited to hear Shannon story and find out more about the differences of not just working in the Philippines, but working in the UK, and how that might different to the United States. Holly, do you want to go ahead and introduce yourself?

Sure. My name is Holly Musselwhite. I'm the clinical educator for Connetics. And I have been with them since last year, late last year. And I've also been a nurse for about 20 plus years, worked in a hospital setting worked in post acute and nursing home long term care settings. And then my career with has fans, you know, kind of back and forth between everything. But I've been doing international clinical nursing, education and training for over eight years now. So I always am fascinated by what I learned from nurses who have practiced overseas and even throughout the US there's practice variations, but certainly, it's never dull, what I'm learning from the nurses that we work with the different things that they do and how they do it.

Thank you Javi. So a great wealth of experience. And definitely I would be really interested to hear your viewpoint. Mark, do you want to go ahead and introduce yourself?

Sure. So my name is Mark Jones, I'm a clinical manager with Amon International. Some of you around the world may know us as a Grady Payton International, still the same company here just a slightly different variation of the name. Been working in healthcare for over 10 years, majority of my time was spent as an ICU nurse, particularly in cvicu. I've also spent a little time emergency department bounced around a few different areas and from what you'll find out when you come here to the USA floated to many different units as well. But for the past three and a half years, have been in my current role as clinical manager here helping nurses in their transition to the US and what it is like to work here give tons of tips, tricks, advice. I have a great support team and I'm happy to join.

Okay, well thank you, Mark. So between Mark and Holly we certainly have a wealth of experience. And of course Connetics USA was acquired by AMSN on chat and you said the 13th You got your results, but it was acquired on May the 13th. So lucky 13. And so we are really honored to be part of the airmen family partnered with O'Grady, Payton and really a wealth of many, many, many years of experience helping nurses to make the transition. Okay, so I see we have many nurses putting their names into the chat. So Shabana, James tagging his friends, Jason from Singapore, leisure from Qatar, bricks from the UK. And we've got Nixey from the UAE Ross from the Philippines. And Paul is tagging her friends, please, if you have questions about ICU specifically, and what the what the differences might be working overseas as opposed to work in the United States, put that into the chat. And I'd be happy to ask the panel any questions that you might have. And if you're not an ICU nurse, and any questions that you might have, just generally clinically, I'd be happy to put to the panel. Okay, so let's talk about ICU. And Shannon, again, let's start with you. What was it like working in the ICU in the Philippines? And how was that different to how you worked in the UK? And how is that different to the US? So,

in the Philippines, I think ICU is pretty much the same, where you have to focus on your patient around one to two patients at a time. And they are the most ill around the hospital like this is the endpoint of their sickness. This is where they go to when they are really sick. So you have to have a very quick decision making Do you have to do like, you have to do multiple tasks at a time and assessment, I think that the very best trait as an ICU nurse when you're working is assessment, because when you see these warning signs, you need to know that, oh, this is an, there's an impending symptom that's coming, then you have to report or collaborate with your colleagues about this is what's happening to my patient, I think this patient needs something. And comparing to, I'd say, from the Philippines, and the UK and the USA, when I was still in the Philippines, I was pretty tired. I mean, I mean, pretty much I'm speaking for all Filipino nurses out there, they're still in the Philippines, I was tired, because the level of acuity and job workload that you do compared to the amount of salary you're earning is, is not at par with each other. And on top of that, sometimes you get to be cold when there's not enough staff, when somebody calls in, you have to come in pretty much the technology that equipment are also different. And what else was I going to say? But yeah, pretty much everywhere you go ICU, in the Philippines, ICU, in the UK ICU in the USA, you need to be focused on your patients. There's not many there, there's not I mean, your patients are not eight patients, there's only one or two of them. And you need to at the whole 12 hours of your shift, you need to be focused on them. I think that that's what I can

see. Okay, okay, great channel. So it sounds like the biggest thing that's the same is that you're dealing with the most critically ill patients, you've got to be collaborating with your colleagues, you know, assessment is really important. And being focused to take care of your patient is is vital, because these are the sickest patients. So that sounds like it's the commonality. And we get to dig a little deeper into the differences in the, in the rest of the show. And but from your perspective, what is the biggest difference between ICU in the UK as opposed to the US

there's, there's a lot actually, but for now, since we're going to cover more of it. I see you in the UK, when I say ICU, they call it in there. And in the UK, it's one to one, that's the ratio here in the US it's to patients is to one nurse. However, in the UK, we don't have a respiratory therapist, it's us that does everything. When patients are on dialysis, we do the dialysis as well. So these patients, most of these patients in the ICU have their own arterial lines. So we're the ones who take their arterial blood gases and run them. And most of and we do win them from the event. So it's from our own judgment, that we can win them from the event because there's no Artis in there.

Okay, okay, so we're gonna dig a little more deeper into that in the, in the rest of the show. So if you only Joining us now we are speaking about ICU specifically, and the differences of working in the ICU overseas, whether it's in the Philippines or the UK, or Dubai, or Singapore, wherever it is, as opposed to work in the United States. And then, and we get to talk about that in a lot more detail. So thank you for that, Shannon. So one thing that comes to mind, let's move on to talking about orientation of coming to the United States, because obviously there's similarities, but there a lot of differences. And Mark, can you share with everybody, in your experience? Why is orientation in coming to the United States so important?

Of course, the orientation, when you arrive here to the US is one of the biggest things that we help support in on the clinical end in your transition. You know, as Shannon mentioned, there's a bunch of different practice differences. But the orientation period really gives you that opportunity to build on your foundation of the different skills, different policies, different procedures, it's very often that you could be doing the same types of skills are same types of nursing interventions. However, maybe here in the US, we do them a little bit differently, or maybe there's a policy that says you have to take an additional step. So that orientation period is crew To show for learning those different things. And oftentimes, you know, maybe you have 10 15 20 years of experience, wherever you are coming from in the world and you feel like an expert in your setting, all of a sudden, when you get here to the US, not only is work new, but everything outside of work is new as well, you can kind of feel like a beginner again, in that orientation period really gives you the opportunity to build on those skills that you know you already have.

Okay, thank you, Mark. So that gives us an idea of what to expect on the orientation side. And Holly, you know, for many international nurses, it really is so unknown, of what to expect in that orientation. And, and that's where I love the look for a talk show. And number four, our admin who give us the opportunity to share with everybody the knowledge because knowledge is power, right of how you what to expect, what give it can you give us an overview of what an ICU nurse can or should expect in terms of orientation when they come to the United States?

Sure, so most acute care settings have developed very formal programs for the ICU setting for orientation. They do that both for new grad nurses, there's a track for them. And there's also a track for new hire nurses with experience. Often hospitals choose to do a hybrid model of some of the new nurse information that might be given and the experienced nurse orientation process. Most hospitals will start with a general orientation that is some large overview topics of standards and principles for the facility. And then they will move within a few days into classroom information related to ICU topics. And that specialty area has so much safety risk to it that it's usually something that's very well thought out. And for the next several weeks, the nurse may go through training on the floor with the preceptor. Some hospitals have training labs where they'll take you in and practice certain skills either as a, a general way to orient or even if you need specific help in a certain area or skill that you're not comfortable with, they'll give you that opportunity. They're looking as well for the nurse to speak up if there's something that they feel they could do better on. So rather than looking at it as admitting you have a weakness, you can say, you know, I'd really like to do a better job. And that's the way that the orientation can also become more tailored for the individual. But for several weeks, you'll have initially some classroom time, and then time with a preceptor where you're on the floor at the bedside doing training. And I would say kind of the minimum I've seen with that is about six weeks. But many times it's going on beyond that to about 12 weeks or more. And most hospitals will tell you that they tried to individualize it if someone is struggling or maybe needs help in a certain area.

Okay, so Mark has told us why orientation and training is so important. And clearly it has given us an idea of what to expect in terms of how much classroom how much on the job orientation and training. Shannon, what was the reality? What was your experience? It was It wasn't can you share with us your experience in terms of orientating when you were in the Philippines in the UK and how that was different in the US.

Alright, so in the Philippines I've worked with two hospitals during my entire career in there. The first hospital I've been with the orientation wasn't that much of a focus pretty much you come into the job, there's a day that you get your you're introduced to, to the staff to the team. And then the next day, you're already doing clinical orientation. So when I worked in another hospital in the city, their orientation was pretty good. I mean, we've had three weeks of full trainings on all the trainings that you need, like refresh, refreshing your IV knowledge, ECG, ECGs, some BLS. And in the UK, it's also the same I mean, there's a few weeks of orientation that you have to go to so these orientation usually consists of what the hospital what the hospital system is, what the hierarchy of the team members, who are these people. Fire Safety, I think that's pretty much almost everywhere. What's the process on like infection control, it's also part of the orientation and some basic nursing skills. It's part of the it's part of the orientation as well. And here in the US, I've had a week of, like corporate orientation. So we were in the classroom, we were, we were told about the vision mission of the hospital, the team members nursing skills. And the next week, we had the whole week to do modules on the computer. And, yeah, there's, there's a lot of modules to do, by the way. And after that week of modules, that's when we did the clinical orientation with the preceptors. So we follow whatever the preceptor preceptors. Schedule is. And as Holly was saying that it is it is it is based on like a clinical track and how many experience you've had. But as a nurse with pretty much, almost 10 years of experience, I pretty much felt like I was I was still beginning again, like I was a beginner. And I've been telling my director that I think the track that I was initially assigned with is, is around like 80 hours. And I told her and she was very much understanding that I think it's better if I do this track, because I am moving not just from one hospital to another and moving from one continent to another and things are, are not the same. So I have to, to go back there and take my time to just adjust with a workplace setting. So I'll be confident enough once I hit the road and start the duty on my own.

Okay, thank you, Shannon. And you mentioned there that you spoke to your director. So we're going to be speaking a little bit about that and how to manage up when you come to the United States and be assertive. So thank you for mentioning that. But I wanted to ask you what did it feel like to be to feel like a newbie when you came to the United States? Because you know, you're an experienced nurse? What does that feel like?

Well, for one, it just felt like I was in a in a different place, I think, well, obviously, I was in a different place in a different country. And as I am now in Tennessee, so sometimes I don't understand what other people are saying it's hard to comprehend the southern accent. And then I even asked my preceptor, she, she's a local, and I told her, Do you guys understand each other? And she told me sometimes you don't even understand each other. So I was like, okay, so it's not just me then coming here as an as an overseas nurse and trying to understand what other people are saying. But yeah, everyone here is very lovely. And they, they know that you are starting and myself as, as for me, I tried to ask several people, not just my preceptor about stuff, because I think as a as a new starter, you need to be proactive for yourself. If there are some things that you need, you need to learn that you don't know and that you're interested and you think that's a vital part. For you to start your work and be on your own, you need to you need to ask, you definitely need to ask and ask several people, you get to learn from different nurses that you work with.

Yeah, thank you, Shannon. I love that you say that. Because for many, especially for the Peano nurses, you know, it's part of the culture to be taught to be shy, to be humble not to ask. And so we're going to talk about that later in the show of just how to be assertive. But Mark What we find with many facilities in the United States right now, many facilities don't have much experience in in orientating international nurses. There's some that do and some that don't, because you know that the shortage is getting worse and worse in the in the more recent years with a pandemic. So, if you if a nurse lands at a facility where maybe the orientation isn't as good as what Shannon has experienced, what should a nurse be doing?

Yeah, I think it's a great question. And what I would say to that is you have to be a great advocate for yourself, you know, you're coming here should have said you're brand new, maybe there's some cultural terms that you don't understand. Maybe you think that your orientations a bit shorter than what it should be. So you really have to open up your communication. You'd have to be proactive in reaching out to your manager, your preceptor, your educator, and the great thing about coming to the US with an agency like Connetics, or you know, Amon International, Gary Payton is you have a clinical support team here as well that you can ask questions to. So you have to really utilize all of your resources that you have. You have to take on that responsibility a little bit yourself. As you mentioned, culturally Are Filipino nurses oftentimes are a little bit more shy, they don't necessarily want to speak up, they're afraid that if they say something they might get in trouble. 100% not the case when working here in the US. And I can tell you that from personal experience, I think I've worked in 14 or 15 different hospitals as a contract nurse here in the US, the biggest thing I have to say is you have to communicate, you have to advocate for yourself and those tougher work environments.

Okay, thank you, Mark, we're going to talk about that a lot, advocate for yourself. And, Holly, if a nurse comes to the United States, and is preparing for their orientation, is there anything that a nurse could do before they arrive here to get you know, quick up to speed?

Absolutely. So if we talk about Conneticor a mn International, both of our companies actually offer some training modules or what we call transitional modules prior to the nurse coming in. That's to kind of also not only maybe refresh information that you already knew, and solidify it a little bit more, but also to give you the opportunity to start to see potential differences. Sometimes the Mark mentioned earlier procedures, things that may seem very normal to people who've practiced in the United States may seem very abnormal to, to someone who hasn't practiced here. And that includes sometimes to more westernized nations or, or locations that had a lot of the technology that Shannon interests mentioned earlier. So looking at what equipment and procedures, key procedures and the sort of the step by step process and best practices. And I think it's important to go back to what Shannon mentioned earlier about knowing your patient. So when they're critically ill, if your assessment skills of listening to lung sounds, listening to heart sounds, assessing skin, assessing circulation and understanding EKGs and how to how to read the basic rhythms at minimum, we want those things to be familiar to you. So while you may have practiced in an ICU setting overseas, there may be significant differences in technology that can be explored prior to arrival, your assessment skills can be practiced. Even just listening to family members, lung sounds, your stethoscope is your is your uniform, or part of your uniform. So doing things like that can help you prepare. But the modules may seem a little bit frustrating when you're juggling so many other things while you prepare to come here. Just understand that when you get to work, if you're scared about the unknown, when you can go back to a solid reference that you've reviewed and say, Okay, this had the principles that I needed to know. So I can fall back on those when I start to get anxious, as well as speaking to your preceptors and your educators. That completes the circle if you're having those resources and looking at things before you come so that you can start to face some of those potential changes early instead of having it all descend all at once.

Okay, so I think as Holly said, it's really important. When you are deciding to come to the United States to do your research, do your homework. This is where the far right is so valuable as a resource to many nurses to be able to share their experiences and learn from each other just like Shannon is sharing with you today. And just let me say kudos to Shannon to coming on the show and sharing your experiences because it is a bit nerve racking to speak to 1000s of nurses all over the world but you really are paying it forward Shannon and helping others and we know that so many nurses are willing to do that. And you know, Mark and Heidi spoke about the clinical programs that transitional module said, you know, a gradient and Connetics do but there are many reputable companies that offer clinical training before you arrive and modules before you arrive. So do your research about that so that you can help prepare yourself and as Mark said, Be an advocate for yourself. And so Alia is watching from Saudi at Silla from India, and James is tagging his friends or Jammas tagging his friends Joven from Philippines Nina's watching Akosua is in the UK. Denise has a question about the Joseph Stilny. And the answer is yes, you can use Joseph Stilny Golf from Pakistan. Just sell his tagging friends vanish from India so people from all over the world are watching today. And just before we move on to kind of the day to day job, Shannon, can you tell our viewers when you think back to you, either leaving the Philippines to go to the UK or leaving the UK to come to the UAS from a clinical perspective, what do you wish someone had told you? Before you started orientation in either of those countries?

I'm trying to think of what the best answer is? Um, I would say, um, I wish people told me that. That No, let me just answer it differently. I think it's, it's pretty much on the job on the site, the orientation that I have experienced from the UK in the US, I think it's perfect. I wouldn't think of anything that I wish people told me about this or that I think they pretty much covered everything, while I was during the orientation. And as for me, I'm a very vocal person, I always, I always express my thoughts. And I always tell them when I'm not sure. So I always, I always think I always write down my question sometimes in like a piece of paper or a notebook. And then I asked them to, to my preceptor or to the director, and I get my answers pretty much correctly and swiftly. So I wouldn't think that there was something that I was missing during those times, because they pretty much covered everything.

So Shannon, was fortunate. And we hope that each and every year when you come to the United States, or if you're already here, and are going through orientation, we hope that you will be like Shannon and have a good experience. But if you don't, as Mark said, You got to be your own advocate. I think that to me, is one of the main messages that that is coming through. And let's move on to talking about on the job, what is it like when you are day to day working in the ICU? And what is that day to day like? So Shannon? Can you maybe share with us the responsibilities of an ICU nurse in the United States and how that might be different to what you experienced before? So just what that what is their day to day like?

All right, so let's start with the shifting. So while I was in the Philippines, and in the UK, the shift is pretty much all over the place. When I was in the Philippines, it was an eight hour shift. So you either get a day shift, an evening shift, or a night shift. While I was in the UK, it was 12, it was 12 hour shift, but you get rotated from day shift to night shift. And well, that was here in the US, if you're a night shift, you're a night shift forever, if you're a day shift, you'll be Dasia forever, which I think is is really the best way to do it. Because you don't get to mess up your body clocks. And if you know what the routine is during the day, then you're pretty much good to go. If you know what the routine is during the night, you're good for the rest of the week. And in here. One of the most one of the best thing that I've that I've experienced compared to my other experiences is we get to do a self schedule. Although requests are subject for approval, but most of them get approved anyway, as a full time staff working in a hospital. So if you want to work just three days a week, you want to work specific, specific days, or if you want to in those in those two pay periods, we call it paid period. So that's a two week schedule, and the next two weeks schedule because we get paid bi weekly if you want to compress all your shifts at the end of the pay period and compress your next shift at the start of the pay period. And you have a lot of days off. So I think I think that's one of the best things here. And I get to hear feedback. People are saying now in the US not much vacation, there is not much PTO and all that. But then you get to choose your own shift. So you pretty much have a lot of vacations in between, I think yeah, it's one of the best things here and I think it's pretty cool that I get to experience it.

Okay, I love that channel. So you really have a lot of autonomy, yes, in how you dictate your time and how you can kind of give yourself that work life balance. I was in the Philippines two weeks ago, and when you were talking about how exhausted you were when you were in the Philippines and the heavy caseload and just thinking back all the nurses that I was speaking to there were they were like, Oh, my goodness, you just don't know where you are. Your body clock is all over the place, because you don't have those straight days or straight nights. Mark, in your experience, are all hospitals, do all hospitals have Self Scheduling?

It's, for the most part, yes. However, if you are coming in as a contract nurse, or if your desire to get here to us, after you get your base experience is to move into something like travel nursing or contract nursing. You know, there may be different facilities that don't necessarily allow Self Scheduling for that particular class of nurse, Corps staff, you know, direct hire placement, more than likely, yes, you're going to have the ability to sell schedule. But keep in mind, you know, depending on the hospital staffing needs, your request for Self Scheduling may not always get granted, as Shannon mentioned, you know, there may be times where the unit is very short staffed to where, you know, everyone wants off on a Thursday or Friday, unfortunately, you know, someone's got to work those days. So, you know, the hospital may go by seniority, they may go in which order they received the request to have that shift off. So there's a lot of different ways that hospitals or even sometimes units within a hospital may approach that Self Scheduling requirement.

Okay. Thank you, Mark. And a follow up question for you. I mean, you're an ICU nurse. And you've also worked with international nurses for many years. What do you what have you seen over the years as the biggest differences on a day to day basis working in the ICU, that an international nurse might experience in the United States,

I would say the biggest thing overall, you probably have to look at it as the big picture is you need to be the driver of the care. And if you don't quite understand what I'm saying when I mentioned that is you as the nurse, you are making the majority of decisions for your patient. Not only are you a self advocate, but you're a patient advocate, you are, you're getting there in the day, you're starting with your report, you're doing your assessments, you're giving your meds, you're making sure orders get carried out on a timely basis. But as we all know, in the ICU patients conditions can shift rapidly, it is up to you to be identifying these changes to go to the physicians or the residents, medical students and say, Hey, here's what's going on, I think we need this medication or this intervention ordered, rather than waiting for the physician to come to you and saying, Okay, this is what's going on, let's do X, Y, and Z. So you really have to be the driver of the care, you have to notice those changes, you know, those rhythm changes, you get to see a patient go from normal sinus rhythm to SPT you have to immediately speak up and say something and act on that particular intervention. And I know we'll get into some assertiveness here in a little bit. But you really have to be the one who drives the care, you know, you do have a lot of autonomy, as Tony mentioned in your scheduling, but you also are very autonomous in your nursing care as well, you need to be the one to kind of identify these different things.

Okay, thank you. Thank you, Mark. And being the driver of the cares is definitely a theme that's coming out of the show, which I think it's important for everybody to hear. I'm just looking in the chat, there are a few people that are talking about, I'm announcing night owl. And I would like to work day shift. So I think and I'm a nocturnal nurse. And so I love that people are commenting there and sharing their preferences. And the great thing about the US is that hopefully, as Mark said, you will be able to get your prep, you know, it might not always be perfect, but you will be able to get your your preference. And Holly, we have a question from Juma who's asking department indicator wise the scope of services must be I think, you know if you can talk maybe a little bit about the scope of responsibilities, and also how the pandemic has factored into that.

So the scope of responsibility for the nurse can be pretty consistent when we talk about the ICU setting, because they're so critically ill we know that the ratios are usually going to be one nurse to two patients, and also that there are ancillary team members like respiratory therapists who are going to be monitoring that patient. Many times they're looking at the ABGs and or excuse me, arterial blood gases, and they are deciding on, you know, maybe this is the best setting that this patient needs on their ventilator to be able to either maintain the status that they're in or to begin weaning off of it. But the responsibilities are also sometimes guided by what other departments the hospital has decided to keep in their team. So sometimes we have specialty nurses who will come in to do services like haemodialysis, or continuous renal therapy CCRT. And we have people who will come to do lab work or blood work or pickup or bring certain things to the nurses. And we also may see that nursing assistants are present or what we call nurse aides or nurse techs may be present. During the pandemic, we saw a lot of hospitals have to get creative with making sure they could meet patient needs. So not only did we see certain zones of the hospital become dedicated to COVID patient populations. We also saw nurses that got crossed trained to be able to work with those patients. We had nurses who might have learned how to work with ventilators who had never really done much of that we had changes in who might be allowed to come on the unit, which meant that if that ancillary department wasn't able to come in and deal with certain things, the nurses might end up being responsible. That could include some things like restocking, so carts might have been left outside of units for them to be brought in and things to be restocked. There were procedures that were put in place that totally changed the flow of how the person moved in and out of the unit. And in and out of rooms. We saw equipment that they wanted to leave outside of rooms so that it could be adjusted for different drip rates and things like that. And so the changes that took place because of COVID. And that pandemic showed, I think that a health care system, who's burdened can also learn very quickly how to try and make changes. So we drive some times in the healthcare world that oh, you know, surely there's a better way to do this? Or why does it take so long to make changes. But when push comes to shove, we've also seen that we can make those changes, it does put a lot of pressure on the nurses and the physicians, we also saw more telehealth, so physicians might want to get the patient from telehealth far away.

So lots of changes that came out of the pandemic. And certainly hospitals had to adapt very quickly with that. And that's where also I think a lot of nurses and not just in the ICU, I've been suffering from burnout. And that's a topic we're going to be talking about in a follow up show. And so moving on now to talk about technology. And I know we have people all over the world here. Paula's watching from Brazil, Jacqueline from Kenya, Joma, from Kenya, Kenya, and so Dong Dong from the UAE, Aquarama, from the UAE, from Ghana, lots of people from all over the world one of the biggest differences got den Xia from Tanzania. What are the biggest differences is the technology when you come to the United States? And Shannon, can you speak a little bit about your experience about technology, and if that was different, or not? For you.

Um, I would say if so, coming from the Philippines, there were two hospitals that I've worked with and in the UK and coming here there's when you go into ICU, they're supposed to be there's always should be an infusion pump or a Syringe Pump, you can just hang it the buter mean or dopamine free flowing, telling you to do 10 drops 10 drops per minute. So there's infusion pumps. However, there are different brands of infusion pumps, so you just have to get acquainted with them. And you will have a lot of time to play around with it anyway. Also, the I think the most different difference would be here in the US. Everything is electronic. So when you come to work, you don't even need to bring a pen with you. I mean, you just have to go to whatever medical record system your hospital have, like for us we have Cerner. So you just bring your badge login and take whatever assessments are in there just basically a tick box. It's not like you do you do like a narrative charting. We don't do that here unless there is a very, an event, a big event that happened to your patient, and you would like to narrate what happened and you'd like to corroborate them also so people can see what your notes are I think that's the only time that I rate. But most of the time, it's just a tick box. Also, the beds, the beds will, there's a weighing scale for the beds. So sometimes, you know, ICU patients, most of them cannot stand or cannot sit. So if there's a certain medication that needs a specific medication that needs, needs a way to calculate the dose, or antibiotics for such, then you can just wait your patient on the bed. ventilators, ventilators here are speaking on my own experience, they have, they have updated to what the latest ventilators are which I think it's fantastic. Because there's more settings that are involved with it. One thing that I have I've been so amazed with when I arrived here is is the pure wick. So this is for your people who don't know what a pure week is. I in here, most facilities, they want to avoid UTI. So as you can't just put a catheter for the reason that you want to. You want to be free of not using a bedpan for your patient because they're, they have a Catholic catheter, they can just pee and it's going to be easy for you. However, in here, they want to avoid indwelling catheters as much so we have a pure week. So it's basically a thing that we put in a female's private part. And they just pee in it. And it gets suction to a suction canister, which, which I think is very amazing at

so many, so many interesting new things to learn about and just see. And so innovative. Mark, you're an ICU nurse, what are some of the latest tips, latest technologies that a nurse might expect to see, depending on the hospital in the ICU?

Yep, I would say pure works definitely want to think that just came around, even in my last year of working the bedside. So it wasn't even around for my whole career. But, as mentioned, you may see, depending on which part of the world you're coming from, you know, if you're working in maybe a smaller community hospital in the Philippines, as opposed to a larger teaching hospital in the UK, your experience with the technology and equipment is probably going to be vastly different. You know, you may see some of the technology pieces. But as Shannon mentioned, it's probably going to be a little bit newer, there's going to be some different buttons on it. You know, you're depending on which specialty of ICU you're working in. So for example, CVICU you may have a different type of CRRT machine, you may have an LVAD, or an impella balloon pump that's different. Or maybe you were working at a hospital that was not really a chest pain center, they did not have a cath lab. So you medically managed any sort of cardiac conditions. So you know, going to a newer institution here in the US, you're probably going to have that impeller balloon pump or something like that available to you. You know, the biggest thing on some of these things that I would say, though, is, you know, I wouldn't say they're necessarily hard to learn, but it's going to take some time and repetition. That's one of the biggest things I tell the nurses that I work with is time and repetition will get you better with that technology, whether it's computerized charting whether it's an IV pump, whether it's a tube feeding pump, many of you may be accustomed to running your tube feedings, or enteral feedings by gravity. And it may be a bolus speed. But here in ICU, you're going to run it over a feeding pump and you're maybe going to run into 60 CC's an hour for a continuous feed 24 hours at a time. So lots of different pieces of technology. It's can be overwhelming. Just know it takes time and repetition. Biggest thing I say,

time and repetition. I like that. I think that's a great way to think about it. Because for many nurses, it's very frustrating. I mean, it's exciting. As Shannon said, you look at things and you're like amazed. Oh my gosh, look at this. And at the same time, it can be frustrating, especially if you come from a country where there is no electronic medical records and you maybe it's not as computer driven. Holly, what can an international nurse do if they come from a country where there's no electronic medical charting? And maybe they haven't seen some of the things that Shannon and Mark have spoken about? Is there anything that can be done before they arrive here?

There is so many systems operate on either laptops or computers that have a desktop computer. So being familiar with the just the device itself, and you know, knowing how to click boxes and stuff. We see nurses who say well I can use the I can use word on my computer, that's a step up from not being able to use words. So getting familiar with basic computer functions not using tablets we see more often, but they're still not mainstream for the majority of the functions that you would be doing in the hospital. So we need a laptop with barcode scanning. The other thing that's really awesome is that all over the web, most vendors have provided videos that will show you like if you look for Cerner, or if you look for epic, those are two main documentation systems. And you will see examples of what that looks like for nurses. So Well, each system can be customized, you would be able to get a glimpse of that before you come here. For some facilities, there may be a little bit of narrative noting, but as Shannon mentioned, most of the time, it's clicking boxes. So be familiar with your mouse with your trackpad on your laptop. And with navigating between screens, and what some of the symbols on your computer may mean. So the inter function and the return function are on the same button. What would I do with that, you know, a very basic so that when you get to the computer itself, you're not feeling timid or uncomfortable, you can demonstrate a decent degree of comfort, and then watch those videos on YouTube that introduce some of those systems, even if it's put out by somebody that you're not going to work for, it will give you a rudimentary idea of what's in the EMR, as well as doing some of those modules that we talked about earlier.

Thank you, Holly. So at least that gives a lot of people comfort to know how to prepare because that's, you know, the Lefora talk show is all about knowledge is power, and how to empower yourself. And before we move on to the final segment, which is the culture that we're on my experience in the ICU in the hospital, and I'm going to just take us one question from Joomla has a question and one researcher protection of nurse various stage in corporate it should be ratline. Now to safe, nurse, workplace trauma legal wise in worldwide every stages, I think I'm not sure exactly what Jim's question is. But I think Juma might be asking about, like, from a legal perspective, if there's a mistake in the ICU, what is power on nurses protected? This is important question, Mark. Maybe you can answer that question for Jim. I think that's what Jim is asking. Yep.

That's a growing topic here in the US, you know, if you've seen the news, you've seen some of the nurses in the news, after they've made a mistake. And the biggest thing I will tell you when it comes to if a mistake happens, because mistakes do happen, that nursing is immediately self reporting in your documentation is key. If you ever you know you find yourself having made an error, or maybe you received a medication from pharmacy, and it's got the patient label on it, and everything. And here in the US, you have to scan your medications, and you scan the medication that scans fine. But then you look at the bag and notice, oh my goodness, there's a different label on this medication. That's the entirely wrong medication, you still have to do your five rights. Even though you have all this technology and all this equipment, you can't forget your fundamentals of nursing, you have to do your five rights of medication administration, you have to know the orders that you are carrying out, you have to understand how to complete the interventions that are you're doing. And if you don't, you have to be able to speak up, grab your charge nurse, grab your mentor, grab your preceptor educator, whoever you can, or just your colleague next door say hey, I've never inserted a nasal gastric tube before. Can you come help me out with this? And then the other situation or questions that we get is, as we've mentioned, maybe you're going to be at an understaffed hospital. You know, maybe that's pretty rare. But sometimes in the ICU, you can end up a one to three ratio with patients, you know, maybe your third one is more of a step down type patient, but there's no room on the step down floor. Now you're feeling a little bit more kind of uneasy, a little bit unsafe at times. So if you feel like you are truly in an unsafe situation, in terms of your patient assignment, you need to one immediately escalate to your charge nurse. If you don't get a satisfactory answer from your charge nurse, you're escalating to the nurse manager and I know what some of you're thinking, Oh, I work night shift, how am I supposed to escalate to the manager, you send an email, always follow up your escalations with an email to that manager to that charge nurse, whoever it might be. That way you are documenting the steps you have taken, then that will in turn help protect you help protect your license. So the key components quickly identifying if an error was made a mistake was made, filing those reports and taking the necessary steps. Don't forget your fundamentals, and then follow up your documentation to the nurse manager with an email.

Okay, very, very important advice everybody from Mark on how to practice safely in the United States. and protect yourself and your patient. And moving on to the work culture. Shannon, this is the last segment we're going to talk about how is the dynamic in the ICU different to the dynamic that you might experience in the United States so, so it has a different in the Philippines as opposed to the United States. So like, what is the relationship like between nurses and their colleagues or nurses and the physician in the Philippines, as opposed to in the United States,

um, in the Philippines, I would say, when doctors come in, you get very intimidated because as a nurse in the Philippines, I mean, I'm speaking on my own experience, I think that's what other people are also experiencing. You, you feel like you're, you're not at level with the doctors, like, you're kind of below them. So you feel intimidated, if you need to ask something you're afraid that you might get, you might get penalized for something you might get reprimand that I was what I was, that what I have experienced before. And you need you need to, you need to do an S bar, you need to, you need to call them on the right and on the right time. And like, you don't just call them for some petty things. So you know what I mean, it's, it's hard to, to, to contact them at the same time. So if you want to call them you need to really make sure that your patient is this and that, and I need your help. However, as for me as a nightshift nurse, we can also call the doctors but we have our nurse, nurse practitioners as well at night. And while I was while I was in the day shift, during preceptorship, period, I think the relationship is pretty good. Like when a doctor's when the doctor is passed by, they're vetted by nurses and they talk about, they talk about random things, not just clinical, like how's their vacation, it's a pretty good relationship, I would say it's  like their friends, it's friendship, it's way beyond being work, work colleagues, it's, you get to ask how the kids are, how's their vacation, which, which I think is very good as in a hospital setting, being able to speak out to your doctor, ask them how things are. That's, that's a very good relationship. And you're not you're not intimidated. And I know, because a in this hospital that I've worked with, and also previously well in the Philippines before, because they're accredited. So Joint Commission DNV, they're several accreditation to the USA, and you know, as a nurse that you are protected, because doctors can just reprimand you for what you've done. Otherwise, they'll be they'll be penalized, they'll have that they'll, they'll get a notice for what they've done. If if you tell your, your director that this is what you've experienced, they're gonna get penalized for it. So as much as possible, they want to have a very good relationship with the nurses, because at the end of the day, when they, when they order something, they want their orders to be done quickly. And if you've had a good relationship with the staff with the nurses, the nurses will be pretty much very eager to do it as much as they can, as quick as they can just to complete that order for that specific patient.

Thank you, Shannon. So it sounds like one of the biggest differences is that in the Philippines, there's a very much a hierarchy. There's the there's the doctors, the physicians, and then the nurses are here, and it's not always, not always easy to communicate. Whereas in the US it's much more in kind of informal, in a way in a lot of ICUs in a lot of hospitals, and you really have to be much more independent. As an ICU nurse in the in the United States and more assertive, and highly many international nurses. You know, as we've said before, I've taught to be shy, taught to be it's part of the culture, it's short, you know, taught to be not assertive. How can an international federal what is assertiveness and how is that different from being aggressive? And how can a nurse be proactively more assertive.

So assertiveness is basically a willingness to speak up and vocalize your concerns and address them head on aggressiveness is seen as more confrontational and has a, it has a more negative connotation because of that. So it's important that you consider the opportunity to be an advocate both for yourself and for the patient is also a duty. So if you don't, that's actually seen as a, an unprofessional thing, if you were to make a mistake, and you know, be trying to address it, and it comes to to be that you didn't speak up, and you didn't make that known, most of the time, that one that needs to be addressed right away, because we want to preview prevent future mistakes. So speaking up before Mistakes happen, because you weren't quite certain, or you were uncomfortable, is actually a safety mechanism. And assertiveness is is not looked upon as a negative thing it's looked upon as a very important skill to have. And I think you can practice it before you get here. So when you're speaking with team members, both on our team or with your colleagues, assertiveness would say, maybe there's something that you feel uncomfortable with, can you can you speak to your colleague even and vocalize? I'm uncomfortable with this? Can you share more? Or can you teach me how you do that? And that's really what we're talking about is speaking up, and being willing to be a little bit vulnerable, but knowing that by doing so, you are advocating for ultimately yourself as well as the safety of the patient. And that is key to any role you're going to play in health care.

Okay, so assertiveness, not aggression, because there's a difference is definitely encouraged in the United States. And that's something as Holly said that we need to practice mock final advice for for international nurses you have you aren't an ICU nurse. And you have seen hundreds of 1000s of nurses come through to you in the United States, what would you say is your final piece of advice mark for, for nurses coming to the United States, ICU nurses,

I would say especially when you're starting out, one of the biggest things is no one knows your clinical skills better than yourself. You know, you know what you are good at, you know what you are not great at and you know, what you just haven't seen? You know, so I think the key and kind of going off, what Holly said is, is you have to speak up, and you have to address situations before they would become an issue. So you know, if you're, you're in your first couple of weeks of getting a new nurse here in the US, as Shannon has mentioned, maybe you're an expert previously, feeling a little bit more new, more of a beginner, you're, you have to say okay, I need some more help in these areas. You know, I need help with my EMR, I need help with this particular intervention. But those other areas that you are competent in, go ahead and show that you are confident in those skills, if you know you are great at assessments, would you get to work, okay, let's assessment and tell that to your preceptor. So they can see that little bit of assertiveness, that proactiveness from you of wanting to go ahead and get those things done. So you can focus more time on those areas that you might need a little bit of improvement. And then secondly, probably one aim would be communication, you have to be able to communicate well, with your colleagues, with your agency with people outside of work, because that is really how you build relationships here in the US is through that open communication, that open dialogue doesn't always have to be talking about clinical talking about work. You know, as you mentioned, you know, how was your vacation? How are the kids? Are they in school, you know, building those relationships through communication, because you'll find that you've learned a lot that may help your clinical practice as well. There's going to be terms that you don't know moving here to the US little slang terms or mentioned those Southern accents. So the more you talk to with people, the more that can in turn, help your clinical performance because now you're learning new things in terms of your communication.

Thank you, mom. So great final words. And at the end of the day, it's about communication. And that really is the key component. I want to thank Shannon, highly and mark for today's show. It was so informative, so interesting to learn about the differences in the ICU from a clinical perspective, from a cultural perspective, what is the orientation, what can one expect, please tag your friends and pay it forward by sharing the show with them. And I want to finish off by thanking again the four admin who do such an amazing job by helping nurses and providing a platform where nurses can help each other. Just a final note before you leave some upcoming shows. So we have on the Canadian Next show and onwards and upwards. Everything that a global healthcare worker needs to know on the 19th of August, we have our regular Question and Answer bringing in the legal immigration panel. On the 26th of August we have the cost of living in the United States how different states have a different cost of living and what to learn about that. September 2 is navigating our unemployment benefits in the United States very confusing for Americans. So just as confusing for international healthcare workers on September 9 is how to buy a house living the American dream. 16th is immigration Q&A. And then the Lefora talk show we'll be back on the 20th of September we'll be looking at clinical differences in the IDI so if you an IDI nurse or you know an IDI nurse, please make sure to note that date. And on the 23rd. We are doing stateside where we will be looking at different states in the United States and what it's like to live as a health care worker. And last but not least the Connetics College. This is every Monday you can go to the Connetics USA page. And there is free information for you to prepare you upcoming shows every week, every Monday on this coming Monday we have Niners one of Kennedy's partners, fabulous, Niners and urban we'll be doing OE T class on the slot writing on the 22nd of August. Thank you everybody for joining us. We look forward to the next Lefora talk show in a month. And thank you again to the panel for sharing your insights, your journey and your wisdom. Bye bye bye